In the Circuit Court of Davidson County, Tennessee (Probate Division)
PERSONAL REPRESENTATIVE STATEMENT
IN THE ESTATE OF:
DOCKET NO: Deceased
I, , Personal Representative of
this estate, as evidenced by my signature below, whether notarized or signed under penalty of
perjury, pursuant to T.C.A. §30-2-601, declare the following: That the estate is solvent; that the
estate has been properly administered; I have paid or settled all claims that were lawfully
presented; that I have paid all expenses of administration; I have mailed or delivered notice of the
requirement to file claims, as prescribed in §30-2-306(d), to the creditors of the decedent who were
known to or reasonably ascertainable; for estates where the death occurred prior to January 1,
2016, I have filed with the Court a final receipt from the Department of Revenue unless waived
pursuant to §67-8-409(g) through the filing of an affidavit; I have filed a release from the TennCare
Bureau pursuant to T.C.A. §71-5-116, or I have stated that the decedent did not attain the age of
fifty-five (55); I have distributed the estate according to the will and obtained and filed receipts for
specific bequests as required by §30-2-707, or I have distributed the estate according to the laws of
intestate succession; and I have obtained and filed acknowledgements from the distributees of the
residue of the estate acknowledging that the estate has been properly distributed to them.
This day of , 20 .
PRINT NAME:
ADDRESS:
Signature
State of County of
Sworn to and subscribed before me, this day of , 20 .
Notary Public / Deputy Clerk
My Commission Expires:
OR
I certify under penalty of perjury that the foregoing is
true and correct.
Signature
Effective 7/1/17